TL;DR: The Centers for Medicare & Medicaid Services modified NCD 363 governing TEER mitral valve coverage, effective January 9, 2026. Here's what billing teams need to act on now.
CMS updated its TEER mitral valve coverage policy under NCD 363 in the Medicare system, and the requirements are detailed and strict. This is Coverage with Evidence Development (CED), which means documentation demands go well beyond standard medical necessity. The policy does not list specific CPT or HCPCS codes — your TEER mitral valve billing will depend on codes your facility has established for this procedure category, but the coverage criteria are non-negotiable regardless of which codes you use.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS |
| Policy | Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation |
| Policy Code | NCD 363 |
| Change Type | Modified |
| Effective Date | January 9, 2026 |
| Impact Level | High |
| Specialties Affected | Interventional Cardiology, Cardiac Surgery, Echocardiography, Heart Failure Cardiology, Structural Heart Programs |
| Key Action | Audit your heart team credentials and documentation processes against NCD 363 v3 criteria before billing any TEER case under Medicare |
CMS TEER Mitral Valve Coverage Criteria and Medical Necessity Requirements 2026
The CMS TEER mitral valve coverage policy covers two distinct patient populations. Getting them confused will cause claim denials.
The first population is patients with symptomatic moderate-to-severe or severe functional mitral regurgitation (MR). These patients must remain symptomatic despite stable doses of maximally tolerated guideline-directed medical therapy (GDMT) plus cardiac resynchronization therapy (CRT), if appropriate. This is not a soft standard — the heart failure cardiologist on your heart team must independently document persistent symptoms.
The second population is patients with significant symptomatic degenerative MR. These cases must be furnished according to an FDA-approved indication. The clinical pathway and documentation requirements differ between functional and degenerative MR, so your team needs separate workflows for each.
Both populations share a foundational requirement: the TEER system used must have received FDA premarket approval (PMA). If your facility is trialing a device that hasn't cleared PMA, Medicare won't cover it under this policy. Full stop.
The Heart Team Requirement Is the Core Medical Necessity Gate
This is where most facilities will struggle. CMS requires that every patient — before and after the procedure — be under the care of a formally constituted heart team. This isn't a checkbox. The policy defines specific credentialing floors for each team member.
Cardiac Surgeon:
| # | Covered Indication |
|---|---|
| 1 | At least 20 mitral valve surgeries per year, or 40 over two years |
| 2 | At least 50% of those must be mitral valve repairs |
| 3 | Board eligible or certified in cardiothoracic surgery |
Interventional Cardiologist:
| # | Covered Indication |
|---|---|
| 1 | At least 50 career structural heart disease procedures, or at least 30 left-sided structural procedures per year |
| 2 | At least 20 career trans-septal interventions, including 10 as primary or co-primary operator |
| 3 | Board eligible or certified in interventional cardiology |
Interventional Echocardiographer (cardiologist or anesthesiologist):
| # | Covered Indication |
|---|---|
| 1 | At least 10 trans-septal guidance procedures and at least 30 structural heart procedures |
| 2 | Board eligible or certified in transesophageal echocardiography with advanced training as required for privileging by the performing hospital |
Heart Failure Cardiologist:
| # | Covered Indication |
|---|---|
| 1 | Required for functional MR patients only |
| 2 | Must have experience treating patients with advanced heart failure |
These aren't aspirational targets. CMS will treat a missing or under-credentialed team member as a failure to meet medical necessity. That means denial, and potentially recoupment on any claims already paid.
The Independent Evaluation Requirement
For functional MR patients, both the interventional cardiologist and the heart failure cardiologist must independently evaluate the patient. Each uses the medical record and a face-to-face examination. CMS does allow one accommodation: if the patient already has an established relationship with a cardiologist experienced in advanced heart failure, the heart failure cardiologist may satisfy this through record and image review instead of a separate face-to-face visit. Document which path you used.
This is Coverage with Evidence Development. That means prior authorization processes at the facility level, registry participation requirements, and ongoing data submission obligations are all in play. If your compliance officer hasn't reviewed your CED participation infrastructure against this updated policy, that needs to happen before January 9, 2026.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Symptomatic moderate-to-severe or severe functional MR — persistent despite maximally tolerated GDMT + CRT (if appropriate) | Covered (CED) | No specific codes listed in policy | Heart failure cardiologist required on heart team; independent evaluation required |
| Significant symptomatic degenerative MR — per FDA-approved indication | Covered (CED) | No specific codes listed in policy | Heart failure cardiologist not required; standard heart team applies |
| TEER using a non-FDA PMA-approved device | Not Covered | N/A | Device must have PMA; no exceptions noted |
| TEER without a qualifying heart team | Not Covered | N/A | All credentialing minimums must be met and documented |
| TEER without patient suitability evaluation documented | Not Covered | N/A | Surgical repair, TEER, and palliative therapy must all be evaluated and documented |
CMS TEER Mitral Valve Billing Guidelines and Action Items 2026
The real issue here isn't understanding the policy — it's translating it into airtight billing workflows before the effective date of January 9, 2026. Here's what to do.
| # | Action Item |
|---|---|
| 1 | Audit every heart team member's credentials against the NCD 363 v3 minimums before January 9, 2026. Pull case volumes and certifications for your cardiac surgeon, interventional cardiologist, and interventional echocardiographer. If anyone falls short, you have a coverage gap, not a documentation gap. Your medical director and compliance officer need to know immediately. |
| 2 | Build a functional MR vs. degenerative MR intake checklist. The documentation paths diverge early. Functional MR cases require the heart failure cardiologist on the team and independent evaluation by both the interventional cardiologist and the heart failure cardiologist. Degenerative MR cases follow the FDA-approved indication pathway. Mixing these up is a fast path to claim denial. |
| 3 | Create a patient suitability evaluation document template. CMS requires that each patient's suitability for surgical mitral valve repair, TEER, and palliative therapy be evaluated, documented, and made available to all heart team members. This must be in the record before you bill. If it's not there, you don't have a defensible claim. |
| 4 | Confirm your FDA PMA documentation is attached to every case file. Your TEER system must have PMA. This sounds obvious, but in a busy structural heart program, device documentation can fall through the cracks. Assign a specific team member to verify and attach PMA documentation for every case before it goes to billing. |
| 5 | Review your CED participation and data submission workflows. Coverage with Evidence Development means CMS ties coverage to registry or study participation. If your program isn't currently enrolled in an appropriate CED study or registry, that's a reimbursement risk on every claim. Talk to your compliance officer about whether your current CED participation satisfies the NCD 363 v3 requirements. |
| 6 | Confirm your charge capture reflects the correct billing structure. The policy does not list specific CPT or HCPCS codes. That's unusual and worth flagging. Work with your coding team to confirm which codes your facility currently uses for TEER procedures and verify that those codes align with how CMS adjudicates NCD 363 claims in your region. Contact your Medicare Administrative Contractor (MAC) if there's any ambiguity about which codes to submit. |
| 7 | Flag this policy for your compliance officer and billing consultant now. The credentialing requirements, CED obligations, and dual-pathway documentation demands make this one of the more complex coverage policies in the structural heart space. If you're not certain your program meets every condition, get expert eyes on it before the effective date — not after a denial. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for TEER Mitral Valve Under NCD 363
The NCD 363 policy document as modified January 9, 2026 does not list specific CPT, HCPCS, or ICD-10 codes. This is worth noting because it creates a gap in standard billing guidelines that your coding team needs to close.
What This Means for TEER Mitral Valve Billing
The absence of codes in the policy document doesn't mean you bill without codes — it means CMS has not enumerated them at the NCD level. Your MAC may have issued a local coverage determination (LCD) or billing article that specifies the appropriate codes for TEER procedures in your region. Check with your MAC before assuming your current code set is correct under the modified policy.
Recommended Steps When No Codes Are Listed
| Step | Action | Who Owns It |
|---|---|---|
| MAC inquiry | Contact your Medicare Administrative Contractor for TEER-specific billing guidance | Billing manager |
| LCD check | Search for any active LCD that references TEER or mitral valve structural heart procedures | Coding team |
| Charge capture review | Confirm your current TEER procedure codes are mapped to the correct revenue codes and DRG pathways | Revenue cycle lead |
| Compliance review | Verify that your code set matches what your facility has used for previously adjudicated TEER claims | Compliance officer |
If your program has billed TEER under Medicare previously and those claims paid, document which codes you used. The modified NCD 363 coverage policy doesn't change the code set — but if your documentation no longer meets the updated criteria, previously used codes will start generating denials.
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